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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604176
Report Date: 11/03/2022
Date Signed: 11/03/2022 11:12:05 AM


Document Has Been Signed on 11/03/2022 11:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
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, CA



FACILITY NAME:ALTA VISTA SENIOR LIVINGFACILITY NUMBER:
374604176
ADMINISTRATOR:ALSPACH, DAVIDFACILITY TYPE:
740
ADDRESS:2041 W VISTA WAYTELEPHONE:
(760) 941-3233
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY:98CENSUS: 74DATE:
11/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Diane DomingoTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to deliver an amended LIC9099 report. LPA was greeted by, identified herself to, and explained the purpose of the visit with Executive Director Diane Domingo.

During today’s visit, LPA obtained Diane Domingo's signature on the amended complaint report dated 5/7/2020.

An exit interview was conducted with Diane Domingo, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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